- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $9,772.37 / $10,715.19
| Facility | | $2,398.83 | $9,772.37 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,715.35 / $8,317.64
| Professional | | $2,570.40 | $3,715.35 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $12,022.64 / $22,908.68
| Facility | | $10,964.78 | $12,022.64 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $6,606.93 / $9,549.93
| Professional | | $3,311.31 | $6,606.93 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $6,025.60 / $10,232.93
| Professional | | $3,801.89 | $6,025.60 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $6,025.60 / $11,220.18
| Professional | | $3,630.78 | $6,025.60 | $11,220.18 |